Thyrotoxic Storm Following Thyroidectomy Follow-up

  • Author: Nafisa K Kuwajerwala, MD; Chief Editor: Arlen D Meyers, MD, MBA   more...
 
Updated: Apr 26, 2010
 

Further Inpatient Care

  • Combined use of propylthiouracil, iodine, and dexamethasone has an effect within 24-48 hours, and the serum levels of T3 and T4 return to normal. Clinical signs of decreasing pulse, normal temperature, and improved mental status mark effective management. Complete recovery takes 10-12 days. Dexamethasone can be tapered thereafter.
  • The three modalities of definitive management are radioiodine, antithyroid drugs, and surgery.
  • Prior to radioiodine therapy or surgery, a patient should be made euthyroid with antithyroid drugs and propranolol. Antithyroid drugs are administered for 12-24 months, during which, a remission may occur. Antithyroid drugs are continued until a normal metabolic state is reached. If in remission, the patient should be closely monitored for 6 months, as relapse is more common during this period after discontinuation of therapy. Iodine is progressively withdrawn. Serially monitor patients until the thyroid gland is sufficiently depleted of its hormone to allow radioiodine therapy. Delaying radioiodine ablation for several months may be necessary because of the large doses of iodine used in management of thyroid storm. Some surgeons may reintroduce iodine for 10 days prior to surgery if subtotal thyroidectomy is planned. Follow patients for up to 5 years.
  • Criteria established by Burch and Wartofsky help in early recognition of impending storm. In thyroid storm, management as described improves the chance of survival.[2]
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Deterrence/Prevention

  • Identification of precipitating factors
    • Surgery and anesthesia induction, labor, thioamide withdrawal, and use of radioiodine are known precipitants of thyroid storm. However, these precipitants may not be discovered frequently.
    • Precipitating factors are not found in all patients, but a meticulous search improves chances for a successful outcome.
    • Chest radiographs and blood, urine, and sputum cultures may be needed to identify intercurrent illness (eg, infection).
    • Judicious use of empiric antibiotics is needed if no obvious source is found.
  • Prevention of recurrence
    • Prevention of a recurrent crisis should be the main objective until completion of definitive therapy.
    • Vigilant monitoring of signs and symptoms of hyperthyroidism during preoperative or pre-anesthetic evaluation is paramount.
    • Consider precipitating factors when deciding on treatment modalities.
    • Adequate control of the thyrotoxic state prior to initiation of definitive therapy is important. Carry out procedures only after the patient is euthyroid.
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Patient Education

For excellent patient education resources, visit eMedicine's Endocrine System Center. Also, see eMedicine's patient education articles Thyroid Problems and Thyroid Storm.

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Contributor Information and Disclosures
Author

Nafisa K Kuwajerwala, MD  Staff Surgeon, Breast Care Center, William Beaumont Hospital

Nafisa K Kuwajerwala, MD is a member of the following medical societies: American College of Surgeons, American Society of Breast Disease, and American Society of Breast Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

Gunateet Goswami, MD  Consulting Staff, Internal Medicine Associates, Mount Clemens, Michigan; Consulting Staff, Department of Cardiology, Henry Ford Hospital

Gunateet Goswami, MD is a member of the following medical societies: American Medical Association, American Society of Echocardiography, and Michigan State Medical Society

Disclosure: Nothing to disclose.

Thabet Abbarah, MD, FACS  Consulting Staff, Department of Otolaryngology, North Oakland Medical Centers

Thabet Abbarah, MD, FACS is a member of the following medical societies: American College of Surgeons

Disclosure: Nothing to disclose.

Venkata Subramanian Kanthimathinathan, MD  Staff Physician, Department of General Surgery, Loma Linda University Medical Center

Disclosure: Nothing to disclose.

Pankaj Chaturvedi, MBBS, MS  Associate Professor, Head and Neck Surgery, Department of Surgical Oncology, Tata Memorial Hospital, India

Pankaj Chaturvedi, MBBS, MS is a member of the following medical societies: American Association for the Advancement of Science, American Head and Neck Society, Association of Surgeons of India, and Indian Academy of Tropical Parasitology

Disclosure: Nothing to disclose.

Specialty Editor Board

Mimi S Kokoska, MD  Associate Professor, Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences; Chief, Department of Otolaryngology-Head and Neck Surgery, Central Arkansas Veterans Healthcare System

Mimi S Kokoska, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Physician Executives, American College of Surgeons, American Head and Neck Society, and Arkansas Medical Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Dean Toriumi, MD  Associate Professor, Department of Otolaryngology, University of Illinois Medical Center

Disclosure: Nothing to disclose.

Christopher L Slack, MD  Private Practice in Otolaryngology and Facial Plastic Surgery, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders

Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA  Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society

Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation Unrestricted gift Unknown; Axis Three Corporation Ownership interest Consulting; Omni Biosciences Ownership interest Consulting; Sentegra Ownership interest Board membership; Syndicom Ownership interest Consulting; Oxlo Consulting; Medvoy Ownership interest Management position; Cerescan Imaging Honoraria Consulting; GYRUS ACMI Honoraria Consulting

References

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  2. Burch HB, Wartofsky L. Life-threatening thyrotoxicosis. Thyroid storm. Endocrinol Metab Clin North Am. Jun 1993;22(2):263-77. [Medline].

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  18. Utiger RD. The thyroid physiology; hyperthyroidism, hypothyroidism, and the painful thyroid. In: Endocrinology and Metabolism. 2nd ed. New York, NY: McGraw-Hill;1987:438.

  19. Wing DA, Millar LK, Koonings PP, et al. A comparison of propylthiouracil versus methimazole in the treatment of hyperthyroidism in pregnancy. Am J Obstet Gynecol. Jan 1994;170(1 Pt 1):90-5. [Medline].

 
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Pathophysiologic mechanisms of Graves disease relating thyroid-stimulating immunoglobulins to hyperthyroidism and ophthalmopathy. T4 is levothyroxine. T3 is triiodothyronine.
Table. Symptoms and Signs of Thyroid Storm When Compared with Uncomplicated Thyrotoxicosis
Uncomplicated ThyrotoxicosisThyroid Storm
1. Heat intolerance, diaphoresis1. Hyperpyrexia, temperature in excess of 106o C, dehydration
2. Sinus tachycardia, heart rate 100-1402. Heart rate faster than 140 beats/min, hypotension, atrial dysrhythmias, congestive heart failure
3. Diarrhea, increased appetite with loss of weight3. Nausea, vomiting, severe diarrhea, abdominal pain, hepatocellular dysfunction-jaundice
4. Anxiety, restlessness4. Confusion, agitation, delirium, frank psychosis, seizures, stupor or coma
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